Trauma: Frostbite

Frostbite

Basics

  • Both Freezing and Reperfusion Contribute to Injury
  • 90% of Injuries Occur in the Hands & Feet from Ages 30-49

Stages

  • Frostnip
    • Formation of Ice Crystals on the Skin Surface
    • Intense Pain with Vasoconstriction, Numbness & Pallor
    • No Long-Term Damage
  • First-Degree
    • Superficial Skin
    • White-Yellow Plaque, No Blister
  • Second-Degree
    • Superficial Clear-Milky Blisters
  • Third-Degree
    • Deeper Hemorrhagic Blisters
  • Fourth-Degree
    • Damage to the Deep Subcutaneous Tissue
    • Skin Becomes Black & Mummified

First Degree Frostbite 1

Frostbite Blisters: Left Clear & Right Hemorrhagic 2

Fourth Degree Frostbite 3

Treatment

  • Initial Tx: Rapid Rewarming in Circulating Water
  • Blister Management:
    • Non-Hemorrhagic:
      • Does Not Interfere with Movement: Nothing
      • Interferes with Movement/Joints: Aspirate or Debride (Controversial)
    • Hemorrhagic: Nothing
  • Avoid Early Debridement/Amputation
    • Demarcates Over Weeks-Months
    • May Require Earlier Debridement if Wet-Gangrene or Sepsis Develop
  • Other Considerations:
    • Consider tPA for Grade 3-4 Injuries if < 24 Hours
    • Consider Prostacyclin (Iloprost) for Grade 2-4 Injuries if < 48-72 Hours
      • Vasodilator May Improve Perfusion

Thrombolysis

  • Limits Microvascular Thrombosis of Reperfusion
  • Indication: Cyanosis Persisting Proximal to the Distal Phalanx (Grade 3-4) & Demonstrated Loss of Perfusion at or Proximal to the Middle Phalanx Immediately After Rewarming
    • *Loss of Perfusion Demonstrated by CTA or Bone Scan (Technetium-99m Scintigraphy)
  • Contraindications:
    • > 6-24 Hours Since Onset
    • Multiple Freeze/Thaw Cycles
    • Any Other General Thrombolytic Contraindications
  • Doing:
    • Bolus 0.15 mg/kg Followed by 0.15 mg/kg/hr Infusion for 6 Hours (100 mg Maximum)
    • Then Give Therapeutic Anticoagulation (Lovenox 1 mg/kg BID) for 14 Days
    • May Consider Catheter-Directed Intra-Arterial Thrombolysis if Available

Frostbite Bone Scan: No Perfusion in Left Digits 3-4 & Right 4-5, Small Uptake in Others 4

References

  1. Sever C, Kulahci Y, Acar A, Duman H. Frostbite injury of hand caused by liquid helium: a case report. Eplasty. 2010 May 19;10:e35. (License: CC BY-2.0)
  2. Gonzaga T, Jenabzadeh K, Anderson CP, Mohr WJ, Endorf FW, Ahrenholz DH. Use of Intra-arterial Thrombolytic Therapy for Acute Treatment of Frostbite in 62 Patients with Review of Thrombolytic Therapy in Frostbite. J Burn Care Res. 2016 Jul-Aug;37(4):e323-34. (License: CC BY-NC-ND-4.0)
  3. Ramdass MJ. Grade IV frostbite requiring bilateral below knee amputations: a case report. Cases J. 2009 Apr 8;2:6635. (License: CC BY-3.0)
  4. Gross EA, Moore JC. Using thrombolytics in frostbite injury. J Emerg Trauma Shock. 2012 Jul;5(3):267-71. (License: CC BY-NC-SA-3.0)